Public Health and Public Good
Simon Finger, The Contagious City: The Politics of Public Health in Early Philadelphia. Ithaca and New York: Cornell University Press, 2012. 248 pp., $39.95.
Simon Finger announces his new book, The Contagious City, as "a political and cultural history" of early Philadelphia "with the medicine put back in" (xi). "Back in?" the reader may instantly query. When was it ever removed? Surely medicine is a scientific subject, following immutable scientific laws, framed to serve both the individual and the common weal?
If, Dear Reader, those are indeed your questions, then you will certainly want to read Finger's book. Historians of medicine often trace the concept of "public health" to the middle of the nineteenth century, when a series of global epidemics led governments in both the United States and Great Britain to assume broad regulatory powers to protect their citizens from contagion. Before governments could assume those powers, however, there had to be a concept of "public," that same public we refer to in "public sphere" (if we have read Jürgen Habermas) or "public opinion" or "public good." This public did not denote merely a physical community, or a population, or set of households, but instead a collectivity wherein all members join together for the benefit of the whole. Finger argues that this concept of "public" already existed in urban communities like eighteenth-century Philadelphia, and that the concept, there as elsewhere, was highly contested. Political actors claimed to be spokespersons for the public in marshaling resources against perceived medical threats, and so debates about medical issues were inextricably intertwined with other political issues and interests. The Contagious City therefore takes seminal moments in the history of Philadelphia and analyzes the ways in which public health came to be understood as a legitimate concern of those entrusted with the public good.
The resolve of Philadelphia's medical elite as well as their patients was quickly tested after the war by the yellow fever epidemic of 1793.
The first two chapters deal with William Penn's vision for a healthy, green city, and the way in which that vision was subverted by Philadelphia's early settlers. Penn was "haunted," Finger notes, "by the living memory of London beset by plague and conflagration" (7). Philadelphia would be different: each settler would cultivate his own house and garden, in the precise rows and squares laid out in Thomas Hulme's 1687 map. The result would be a morally and physically healthy city. But Penn could do nothing to stop settlers from subdividing their lots to increase their rents, or from squatting in caves along the Delaware if that assisted their trade. By the end of the seventeenth century, Philadelphia was not a green and pleasant English country town, but rather an expanding mercantile city with all the sources of contagion Penn sought to leave behind in London: a raucous dockside shanty-town, streets running with sewage and blood from butchers' shops, and an exploding population.
From the first, that population had been politically divided. Those divisions deepened as German immigrants and Acadian refugees entered the city in increasing numbers from the 1750s. Finger traces the way in which apparently purely medical topics were deeply entwined in party politics. Philadelphia, like all port cities, faced danger from shipborne diseases, but quarantining newly arrived immigrants led to serious hardships. When Governor George Thomas proposed a marine hospital "as a humane alternative to confining passengers to their sickly vessels" (43), it quickly escalated into a fight with his political opposition.
Only slightly less politicized were the efforts of medical reformers in the 1760s and 1770s. Finger places the formation of Philadelphia's medical elite, and institutions such as the College of Physicians and Pennsylvania Hospital, in the context of a transatlantic ideology of improvement. Many of the great names of Philadelphia medicine, like Benjamin Rush, John Morgan, and William Shippen, had studied in Edinburgh and believed British medical ideas were the best suited for their rapidly expanding city. They were proud of Philadelphia as an imperial metropole, one of many loci on both sides of the Atlantic in which ideas and affiliations—as well as diseases—circulated freely. But in medicine, as in government, Americans were increasingly conscious of discontinuities between themselves and Greater Britain. James Hutchinson, part of the second generation of Philadelphia medical students to study in Edinburgh, ignored all practical advice and made the dangerous journey home in 1777, eventually going to war against his former mentors.
The Revolutionary War mobilized Philadelphia medical men to act as practitioners and administrators, to apply lessons of urban hygiene to military camps. The infighting among these men about how to run the newly fledged medical service of the equally new Continental Army has been well documented elsewhere, and Finger spends little time discussing it. Instead, he argues that even the highly publicized conflict between Morgan and Shippen was a necessary apprenticeship for the creation of an effective military medical service. "The doctors," he notes, "achieved real and measurable improvements by the end of the fighting" (102). They emerged as a solid professional cadre, ready to serve the new Republic in peace as they had served formerly in war.
The resolve of Philadelphia's medical elite as well as their patients was quickly tested after the war by the yellow fever epidemic of 1793. This is arguably the most famous episode in Philadelphia's medical history, and once again, The Contagious City does not linger over well-trodden ground. As is common in epidemics, both political and medical unity fell apart, to then be painstakingly put back together by an alliance between Governor Thomas Mifflin and medical elites. Mifflin worked with members of the College of Physicians of Philadelphia to strengthen existing public health measures, creating a board of health and rallying citizen support. Finger points out both individual and communal acts of kindness; he points out, too, the ingratitude of commentators who urged white Philadelphians to hire African Americans as servants and nurses, yet accused the latter of negligence and outright theft. Religious leaders Richard Allen and Absalom Jones responded to the charges, their rebuttal and the ensuing discussion serving ultimately to include African Philadelphians in the group denoted by the term "public" in "public health" and "public good."
After 1793, Finger notes, "institutional medical authorities" within Philadelphia "constantly augmented both their powers and the physical infrastructure of quarantine" (148). Yet the unity that grew out of the city's epidemic history could not be translated into national legislation. All quarantine measures remained the prerogative of local and state governments until the end of the nineteenth century.
For this reviewer, The Contagious City is best read as a local study, a thick description of the emergence and development of a public forum in Philadelphia for debate on medical issues. Though Finger provides a preface linking the study to broader issues in the history of medicine, environment, and population, a more detailed discussion of the book's context in the rich historiography of Philadelphia and mid-Atlantic urban culture would have been useful. And Finger's argument in the last chapter that debates in Philadelphia shaped national attitudes toward health and contagion is unconvincing: public discussions of, and solutions to, public health issues continued to be intensely local through the nineteenth and twentieth centuries. As his own case study ably demonstrates, Americans may claim to think globally about fundamental issues in medicine, but we talk and act locally. There were to be myriad small, intensely debated, locally politicized responses to medical threats before even a limited national consensus could emerge on public health. Even today, all but the most basic issues of public hygiene are shaped by local political agendas, cultural experiences, and historical contingencies. Public health, like the public good itself, still lies very much in the eye of the beholder.
Finger's The Contagious City provides an excellent and inclusive view of medicine from the perspective of early Philadelphians. It is a valuable contribution to early American urban and medical history.
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